RESUMO
OBJECTIVE: To study the incidence, patient and event characteristics, and outcome of rapid response system (RRS) activation on an in-hospital haemodialysis unit. DESIGN: Retrospective review of all RRS events on an in-hospital 10-bed haemodialysis unit over a 64-month period (November 2001 to February 2007). SETTING: University of Pittsburgh Medical Center Presbyterian Hospital, a 730-bed academic, urban, tertiary care adult hospital in the USA. Interventions None. RESULTS: Over a 64-month-period, 107 of 8928 patients undergoing haemodialysis on the dialysis unit required an RRS activation (12 events/1000 patients dialysed). The most common reasons for RRS activation were respiratory distress/hypoxaemia (27%) and mental status change (24%). Predictors of in-hospital mortality included old age (33% in-hospital mortality for patients aged 65 years or older vs 14% for patients aged less than 65 years; χ(2) = 5.66, df = 1, p = 0.017), and RRS activation due to a respiratory abnormality (37% mortality for respiratory codes vs 18% for all other codes; χ(2) = 4.12, df = 1, p = 0.042). Surprisingly, only 71% of the patients who had an RRS event had the event as dialysis was occurring. Twenty-four patients (22%) met one or more RRS activation criteria upon first vital sign check in the dialysis unit; RRS was activated on 12 (11%) of these patients before dialysis was started. Nineteen (18%) additional patients had an RRS event after their dialysis session had ended, while awaiting transport back to their unit. CONCLUSIONS: From our findings, it can be suggested that critical events often occur before and after dialysis treatment, during or awaiting transport. Careful assessment of these high-risk patients before and after transport, to and from the dialysis unit may be warranted.
Assuntos
Unidades Hospitalares de Hemodiálise , Equipe de Respostas Rápidas de Hospitais , Avaliação de Resultados em Cuidados de Saúde , Centros Médicos Acadêmicos , Adulto , Bases de Dados Factuais , Feminino , Hospitais com mais de 500 Leitos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/métodos , Pennsylvania , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: To study the medical emergencies occurring on a tertiary otolaryngology service identified using a rapid response system (RRS). DESIGN: Retrospective chart review of RRS activations during 21 months. SETTING: Specialised otolaryngology care unit within the University of Pittsburgh Medical Center Presbyterian/Montefiore Hospital, a tertiary, academic, teaching hospital in the USA. INTERVENTION(S): None. RESULTS: 1171 unit admissions. Unit mortality was 5.1/1000 admissions. 53 patients were involved in 67 RRS activations (4/53 deaths). 32 of 67 events were due to respiratory derangements, most commonly pneumonia. 18 of 67 events were due to cardiovascular abnormalities, most commonly hypertension and myocardial infarction. 11 of 67 events were secondary to mental status changes, several of which were related to adverse drug events. 6 of 67 events were secondary to acute bleeding. 23 of 67 events occurred within 24 h of patient transfer/admission, 14 of those after operations. RRS activation was a marker for in-hospital death (RR 42.2, 95% CI 7.9 to 225.2) compared with that in patients not activating the RRS. CONCLUSIONS: Although otolaryngology care units attempt to prevent adverse events, emergencies still occur. RRSs identify deteriorating otolaryngology patients who are at increased risk for mortality. RRSs are an efficient mechanism of intervention during a medical emergency. RRSs provide a convenient method of identifying medical/system errors and educational opportunities.
Assuntos
Cuidados Críticos/métodos , Otolaringologia/normas , Gestão da Segurança , Humanos , Garantia da Qualidade dos Cuidados de Saúde , Estudos RetrospectivosRESUMO
Medical emergency teams (METs) were developed to respond more rapidly to changes in patient condition. While effective, METs do not address events prior to the response. This study examined differences in patient, nurse, and organisational characteristics for 108 MET calls on five medical and five surgical units in a university hospital. MET calls occurred more often on the day shift (p = 0.007) for medical (p = 0.036), but not surgical, patients. Of the 108 events, 44% were delayed, defined as events with documented evidence that pre-established criteria for a MET call were present for >30 min. More delays occurred on the night shift (p = 0.012). Delayed events were not related to the number of patients assigned (p = 0.608). However, there was a trend for more delays when more patients were assigned (4:1 = 21% vs 6:1 = 43%). In a logistic regression model, shift and patient-unit-match (medical, surgical) were significant predictors of delays. The model correctly predicted 68% of delayed events. Study findings indicate that a combination of patient, nurse and organisational characteristics influence timely rescue.
Assuntos
Medicina de Emergência/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Dor no Peito/terapia , Dispneia/terapia , Emergências/enfermagem , Unidades Hospitalares , Humanos , Estudos Retrospectivos , Centro Cirúrgico Hospitalar , Fatores de Tempo , Resultado do TratamentoRESUMO
Donation after cardiac death (DCD) is uncommon in part because clinicians cannot prospectively identify patients who are likely to die within 60 min of withdrawal of life-sustaining treatments (LST). UNOS criteria exist but have not been validated. Consecutive patients electively withdrawn from LST at five university-affiliated hospitals were prospectively enrolled. Demographic and treatment characteristics were collected. Chi-square was used to determine risk for death within 60 min and validate the UNOS criteria. A total of 533 patients were enrolled. A total of 28 were excluded from this report due to age <18 years or failure to include time of death. Of 505 (95%) patients, 227 (45%) died within 60 min, 134 (27%) in 1-6 h and 144 (29%) >6 h after withdrawal of LST. A total of 29%, 52%, 65% and 82% of patients with 0,1,2 and 3 UNOS DCD criteria, respectively, died within 60 min of withdrawal of LST. The data validate the UNOS criteria. Patients with no criteria might be excluded from consideration for DCD. Those with more than one criterion are reasonable candidates, while those with a single criterion should be considered if a 50% failure rate for DCD is acceptable.
Assuntos
Morte Súbita Cardíaca/epidemiologia , Doadores de Tecidos/estatística & dados numéricos , Idoso , Feminino , Hospitais Universitários , Humanos , Sistemas de Manutenção da Vida , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estatísticas não Paramétricas , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/estatística & dados numéricosRESUMO
PROBLEM: Sliding scale insulin (SSI) is frequently used for inpatient management of hyperglycemia and is associated with a large number of medication errors and adverse events including hypoglycemia and hyperglycemia. DESIGN: Observational before and after study evaluating the impact of implementation of a standardized SSI protocol and preprinted physician order form. SETTING: University Hospital in Pittsburgh, PA, USA. STRATEGY FOR CHANGE: Guidelines for the use of SSI were created by an interdisciplinary committee and implemented in non-intensive care units. In addition, a preprinted physician order sheet was developed which included the guidelines and an option for ordering one of three standardized insulin sliding scales or a patient specific scale. EFFECT OF CHANGE: One year after implementation the physician order form was used for 91% of orders and, overall, 86% of SSI orders followed the guidelines. The number of prescribing errors found on chart review was reduced from 10.3 per 100 SSI patient-days at baseline to 1.2 at 1 year (p = 0.03). The number of hyperglycemia episodes 1 year after implementation decreased from 55.9 to 16.3 per 100 SSI patient-days. LESSONS LEARNT: The protocol was readily accepted by hospital staff and was associated with decreased prescribing errors and decreased frequency of hyperglycemia.
Assuntos
Protocolos Clínicos , Diabetes Mellitus Tipo 1/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hiperglicemia/tratamento farmacológico , Hipoglicemiantes/administração & dosagem , Insulina/administração & dosagem , Erros de Medicação/prevenção & controle , Guias de Prática Clínica como Assunto , Glicemia/análise , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 2/complicações , Fidelidade a Diretrizes , Unidades Hospitalares/normas , Hospitais Universitários/normas , Humanos , Hiperglicemia/etiologia , Hipoglicemia/etiologia , Hipoglicemiantes/efeitos adversos , Insulina/efeitos adversos , Sistemas de Registro de Ordens Médicas , PennsylvaniaRESUMO
A national conference on organ donation after cardiac death (DCD) was convened to expand the practice of DCD in the continuum of quality end-of-life care. This national conference affirmed the ethical propriety of DCD as not violating the dead donor rule. Further, by new developments not previously reported, the conference resolved controversy regarding the period of circulatory cessation that determines death and allows administration of pre-recovery pharmacologic agents, it established conditions of DCD eligibility, it presented current data regarding the successful transplantation of organs from DCD, it proposed a new framework of data reporting regarding ischemic events, it made specific recommendations to agencies and organizations to remove barriers to DCD, it brought guidance regarding organ allocation and the process of informed consent and it set an action plan to address media issues. When a consensual decision is made to withdraw life support by the attending physician and patient or by the attending physician and a family member or surrogate (particularly in an intensive care unit), a routine opportunity for DCD should be available to honor the deceased donor's wishes in every donor service area (DSA) of the United States.
Assuntos
Morte Súbita Cardíaca , Obtenção de Tecidos e Órgãos/ética , Adolescente , Adulto , Criança , Humanos , Transplante de Fígado/mortalidade , Transplante de Fígado/estatística & dados numéricos , Pessoa de Meia-Idade , Seleção de PacientesRESUMO
PROBLEM: Advance cardiac life support (ACLS) training does not address coordination of team resources to improve the ability of teams to deliver needed treatments reliably and rapidly. Our objective was to use a human simulation training educational environment to develop multidisciplinary team skills and improve medical emergency team (MET) performance. We report findings of a crisis team training course that is focused on organization. SETTING: Large center for human simulation training at a university affiliated tertiary care hospital. PARTICIPANTS: Ten courses were delivered and 138 clinically experienced individuals were trained (69 critical care nurses, 48 physicians, and 21 respiratory therapists). All participants were ACLS trained and experienced in responding to cardiac arrest situations. COURSE DESIGN: Each course had four components: (1) a web based presentation and pretest before the course; (2) a brief reinforcing didactic session on the day of the course; (3) three of five different simulated scenarios; each followed by (4) debriefing and analysis with the team. Three of five simulator scenarios were used; scenario selection and order was random. Trainees did not repeat any scenario or role during the training. Participants were video recorded to assist debriefing. Debriefing focused on reinforcing organizational aspects of team performance: assuming designated roles independently, completing goals (tasks) assigned to each role, and directed communication. MEASURES FOR IMPROVEMENT: Participants graded their performance of specific organizational and treatment tasks within specified time intervals by consensus. Simulator "survival" depended on supporting oxygenation, ventilation, circulation within 60 seconds, and delivering the definitive treatment within 3 minutes. EFFECTS OF CHANGE: Simulated survival (following predetermined criteria for death) increased from 0% to 89%. The initial team task completion rate was 10-45% and rose to 80-95% during the third session. LESSONS LEARNT: Training multidisciplinary teams to organize using simulation technology is feasible. This preliminary report warrants more detailed inquiry.
Assuntos
Simulação por Computador , Medicina de Emergência/educação , Equipe de Assistência ao Paciente , Ressuscitação/educação , Gestão da Segurança , Currículo , Interpretação Estatística de Dados , Parada Cardíaca/terapia , Humanos , Internet , Erros Médicos , Enfermeiras e Enfermeiros , Médicos , Terapia Respiratória , Fatores de TempoRESUMO
BACKGROUND: Medical emergency team (MET) responses have been implemented to reduce inpatient mortality, but data on their efficacy are sparse and there have been no reports to date from US hospitals. OBJECTIVES: To determine how the incidence and outcomes of cardiac arrests have changed following increased use of MET. METHODS: Objective criteria for MET activation were created and disseminated as part of a crisis management program, after which there was a rapid and sustained increase in the use of MET. A retrospective analysis of clinical outcomes was performed to compare the incidence and mortality of cardiopulmonary arrest before and after the increased use of MET. RESULTS: A retrospective analysis of 3269 MET responses and 1220 cardiopulmonary arrests over 6.8 years showed an increase in MET responses from 13.7 to 25.8 per 1000 admissions (p<0.0001) after instituting objective activation criteria. There was a coincident 17% decrease in the incidence of cardiopulmonary arrests from 6.5 to 5.4 per 1000 admissions (p = 0.016). The proportion of fatal arrests was similar before and after the increase in use of MET. CONCLUSIONS: Increased use of MET may be associated with fewer cardiopulmonary arrests.
Assuntos
Protocolos Clínicos , Serviço Hospitalar de Emergência/normas , Parada Cardíaca/terapia , Sistemas de Comunicação no Hospital , Equipe de Assistência ao Paciente , Sistemas de Comunicação entre Serviços de Emergência , Parada Cardíaca/mortalidade , Mortalidade Hospitalar , Hospitais Universitários/normas , Humanos , Unidades de Terapia Intensiva/normas , Sistemas Multi-Institucionais , Estudos de Casos Organizacionais , Avaliação de Resultados em Cuidados de Saúde , Pennsylvania/epidemiologia , Avaliação de Programas e Projetos de Saúde , Estudos RetrospectivosRESUMO
BACKGROUND: No previous studies have investigated whether medical emergency team (MET) responses can be used to detect medical errors. OBJECTIVES: To determine whether review of MET responses can be used as a surveillance method for detecting medical errors. METHODS: Charts of all patients receiving MET responses during an 8 month period were reviewed by a hospital based Quality Improvement Committee to establish if the clinical deterioration that prompted the MET response was associated with a medical error (defined as an adverse event that was preventable with the current state of medical knowledge). Medical errors were categorized as diagnostic, treatment, or preventive errors using a descriptive typology based on previous published reports. RESULTS: Three hundred and sixty four consecutive MET responses underwent chart review and 114 (31.3%) were associated with medical errors: 77 (67.5%) were categorized as diagnostic errors, 68 (59.6%) as treatment errors, and 30 (26.3%) as prevention errors. Eighteen separate hospital care processes were identified and modified as a result of this review, 10 of which involved standardization. CONCLUSIONS: MET review may be used for surveillance to detect medical errors and to identify and modify processes of care that underlie those errors.
Assuntos
Serviço Hospitalar de Emergência/normas , Auditoria Médica , Erros Médicos/prevenção & controle , Equipe de Assistência ao Paciente , Vigilância de Evento Sentinela , Humanos , Unidades de Terapia Intensiva/normas , Erros Médicos/classificação , Sistemas Computadorizados de Registros Médicos , Sistemas Multi-Institucionais , Pennsylvania , Avaliação de Processos em Cuidados de Saúde , Análise de SistemasRESUMO
Physicians are taught that the foundation of the physician-patient relationship is trust, and trust is based in part on truthfulness. While drawing important "lines in the sand" regarding whether and why to tell the truth, ethics codes promulgating honesty fail to provide clinicians with guidance regarding what is the truth, as well as when and how to disclose it. These issues may be at the core of why an adverse event is left undisclosed. Consistently being truthful in the setting of an error is particularly difficult and requires overcoming a number of institutional and personal barriers. The article concludes that if delivering "the truth" is important, then articulation of criteria for determining what should be told, by whom, and when is essential. A policy that considers the practical issues and provides guidance may be useful.
Assuntos
Hospitais , Erros Médicos , Política Organizacional , Revelação da Verdade , Revelação , Ética Institucional , Ética Profissional , Família , HumanosRESUMO
In the past, inadequate diagnostic instruments sometimes led to incorrect diagnoses of death, so careful and prolonged observation--the "death watch"--was required. Diagnostic instruments are now accurate and determining the presence or absence of circulation and cerebral function is easy in virtually all cases. Still, ambiguity and controversy in diagnosing death persists because the current criteria, irreversible cessation of cardiac or whole brain function, are ambiguous. Recent reintroduction of non-heart-beating organ donation has highlighted the controversy. Data on the ability to achieve restoration of spontaneous circulation are quite consistent, but they support several different sets of reasonable death criteria. This article concludes with a rejection of a fixed notion of "irreversibility" because it does not conform to current practice, is potentially deleterious to social events at the time of death, and the reversibility of cardiopulmonary arrest is dependent on available means of resuscitation. Finally, the time required to ensure irreversible cessation of cardiac function despite potential intervention is too broad to be clinically applicable and is unreasonable. Diagnosis of death should be based on the context in which it occurs because the medical means available determine what is irreversible.
Assuntos
Morte Encefálica/diagnóstico , Atestado de Óbito , Parada Cardíaca/diagnóstico , Monitorização Fisiológica/métodos , Seleção de Pacientes , Obtenção de Tecidos e Órgãos/métodos , Medicina Baseada em Evidências , Humanos , Cuidados para Prolongar a Vida/métodos , Futilidade Médica , Guias de Prática Clínica como Assunto , Ressuscitação/métodos , Fatores de TempoAssuntos
Unidades de Terapia Intensiva , Cuidados Paliativos/métodos , Assistência Terminal , Analgésicos Opioides/administração & dosagem , Tomada de Decisões , Ética Médica , Família , Humanos , Cuidados para Prolongar a Vida , Manejo da Dor , Medição da Dor , Equipe de Assistência ao Paciente , Relações Profissional-FamíliaRESUMO
Although 69 to 75 percent of U.S. adults say they would be willing to become organ donors, half of the families that are asked to consider donating the organs of a deceased family member refuse to consent. This discrepancy is most noticeable when the refusal of a family conflicts with the known wishes of a patient. It is the practice of nearly all organ procurement organizations in the United States not to procure organs or tissue when families refuse, even if the patient's wishes have been documented. Recently, the Center for Organ Recovery and Education (CORE) adopted a controversial policy of acting on the documented wishes of individuals to donate, independent of family consent. An examination of the moral and political issues raised by this policy lead to the conclusion that the CORE policy is not only justified, but morally required.
Assuntos
Tomada de Decisões , Família/psicologia , Doadores de Tecidos/psicologia , Dissidências e Disputas , Ética Médica , Humanos , Consentimento Livre e Esclarecido , Intenção , Responsabilidade Legal , Estados UnidosRESUMO
OBJECTIVE: Non-heart-beating organ donation for transplantation is increasing despite the concern whether all the donors are dead. This concern is based on the adequacy of documentation of death and the appropriate duration that circulation and respiration should be absent before death certification. No studies have examined the documentation and deaths of patients who became non-heart-beating organ donors. DESIGN: Retrospective study of observational data. PATIENTS: All non-brain-dead patients who became non-heart-beating organ donors at the University of Pittsburgh Medical Center from January 1, 1993, to June 30, 1998, were identified. Records for 15 of 16 patients were available for review. MEASUREMENTS AND MAIN RESULTS: Adequacy of documentation, extubation time, onset of severe hypotension, duration of absent circulation before death was certified, and the time of incision for organ procurement were ascertained. Twelve of 15 records had all required clinical documentation. The mean age of patients was 46.5 +/- 5.7 yrs. All 15 patients were extubated before death and had femoral arterial catheters; one had a biventricular assist device discontinued. The time of hypotension and pulselessness was not documented for one and three patients, respectively. All 12 patients with documentation had > or =2 mins of absent circulation. Time from certification to incision for procurement was 1.1 +/- 2.3 mins. CONCLUSIONS: In a small study of non-heart-beating organ donation, circulation never resumed after >1 min of absent circulation, suggesting that 2 mins of absent circulation is sufficient to certify death. Three of 15 patients had inadequate documentation. Gaps and inconsistencies in documentation may raise concern about the potential for abuse.
Assuntos
Cuidados para Prolongar a Vida , Doadores de Tecidos , Adulto , Morte Encefálica , Feminino , Coração/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosAssuntos
Tomada de Decisões , Ética Médica , Eutanásia Passiva/psicologia , Cuidados para Prolongar a Vida/psicologia , Competência Mental , Autonomia Pessoal , Quadriplegia/psicologia , Doadores de Tecidos/psicologia , Obtenção de Tecidos e Órgãos , Suspensão de Tratamento , Adulto , Morte Encefálica , Protocolos Clínicos , Eticistas , Humanos , Masculino , Quadriplegia/terapiaRESUMO
Organ transplantation is an accepted therapy for major organ failure, but it depends on the availability of viable organs. Most organs transplanted in the U.S. come from either "brain-dead" or living related donors. Recently organ procurement from patients pronounced dead using cardiopulmonary criteria, so-called "non-heart-beating cadaver donors" (NHBCDs), has been reconsidered. In May 1992, the University of Pittsburgh Medical Center (UPMC) enacted a new, complicated policy for procuring organs from NHBCDs after the elective removal of life support. Seventeen months later only one patient has become a NHBCD. This article describes her case and the results of interviews with the health care team and the patient's family. The case and interviews are discussed in relation to several of the ethical concerns previously raised about the policy, including potential conflicts of interest, the definition of cardiopulmonary death, and a possible net decrease in organ donation. The conclusion is reached that organ procurement from non-heart-beating cadavers is feasible and may be desirable both for the patient's family and the health care providers.